New insights into tip supporting structures. Consequences for nasal surgery.

BACKGROUND: Knowledge of tip supporting structures is crucial for successful rhinoplastic surgery. The aim of this study was to provide detailed anatomical and histological descriptions of the tip supporting structures. METHODS: Serial coronal sections of the entire external noses from seven cadavers were studied after staining by Mallory-Cason and Verhoeff-Van Gieson procedures. RESULTS AND CONCLUSIONS: We found no histological evidence of ligaments between the cartilaginous- and bony parts of the nasal skeleton, and between the skin and the nasal skeleton. Instead, we found a perichondrial-periosteal lining within the soft tissue envelope. The main tip supporting and shaping structures are: septal and lobular cartilages, premaxillae, and the soft tissue envelope including the periosteal-perichondrial envelope/membrane. These findings may have clinical relevance in functional and aesthetic rhinoplasties.

Saddle nose deformity and septal perforation in granulomatosis with polyangiitis.

BACKGROUND: Patients who have granulomatosis with polyangiitis (GPA, syn. M. Wegener) often develop an external nose deformity which may have devastating psychological effects. Therefore, reconstruction of nasal deformities by rhinoplasty may become necessary to achieve a normal appearance. OBJECTIVE OF REVIEW: The aim of this systematic review was to investigate the efficacy and safety of surgical reconstruction in external nasal deformities and septal perforation in GPA patients. SEARCH STRATEGY: A systematic literature search with defined search terms was performed for scientific articles archived in the MEDLINE-Database up to 10 June 2016 (PubMed Advanced MEDLINE Search), describing management of cases or case series in GPA patients with saddle nose deformity and/or septal perforation. RESULTS: Eleven of 614 publications met the criteria for this analysis including 41 GPA patients undergoing external nasal reconstruction and/or septal reconstruction with a median follow-up of 2.6 years. Overall, saddle nose reconstruction in GPA patients is safe even if an increased rate of revision surgery has to be expected compared with individuals without GPA undergoing septorhinoplasty. Most implanted grafts were autografts of calvarial bone or costal cartilage. For septal perforation reconstruction, few studies were available. Therefore, based on the available data for surgical outcomes, it is impossible to make evidence-based recommendations. All included GPA patients had minimal or no local disease at the time of reconstructive surgery. Therefore, the relationship between disease activity and its impact on surgical outcomes remains unanswered. The potential impact of immune-modulating medications on increased complication rates and the impact of prophylactic antibiotics are unknown. CONCLUSIONS: This study systematically reviews the efficacy and safety of surgical reconstruction of external nasal deformities in GPA patients for the first time. Saddle nose reconstruction in GPA patients with minimal or no local disease is a safe procedure despite an increased rate of revision surgery. Further research is required regarding the impact of antibiotic prophylaxis, immune-modulating therapy, long-term outcomes and functional outcomes measured with subjective and objective parameters.

The injectable filler in rhinoplasty: not a complication-free alternative.

The injectable filler in rhinoplasty: not a complication-free alternative. PROBLEM: Non-surgical or "filler" rhinoplasty seems an attractive tool to fine-tune the aesthetic results of surgery; its use as a primary technique is also increasingly popular. However, physicians performing these procedures should be aware that they are not complication-free. METHODOLOGY/RESULTS: In two case studies we now describe potential foreign body reactions, resulting in granulomas, to first generation silicone oil fillers, and second generation injectable hyaluronic acid fillers. CONCLUSIONS: Foreign body reactions are especially prevalent against permanent fillers, particularly silicone, and ideally these should be abandoned. Given that granulomas can also be provoked by temporary and semi-permanent fillers, we would advise restraint in their use, with appropriate vigilance to ensure the early recognition of complications. The increasing popularity of filler rhinoplasty will likely provoke a higher incidence of complications in the future. Intralesional steroid injections can be attempted as a treatment, although surgical resection of these "granulomas" may ultimately be required.

Assessing the efficacy of candidate mosquito repellents against the background of an attractive source that mimics a human host.

Mosquito repellents are used around the globe to protect against nuisance biting and disease-transmitting mosquitoes. Recently, there has been renewed interest in the development of repellents as tools to control the transmission of mosquito-borne diseases. We present a new bioassay for the accurate assessment of candidate repellent compounds, using a synthetic odour that mimics the odour blend released by human skin. Using DEET (N,N-diethyl-meta-toluamide) and PMD (p-menthane-3,8-diol) as reference compounds, nine candidate repellents were tested, of which five showed significant repellency to the malaria mosquito Anopheles gambiae sensu stricto (Diptera: Culicidae). These included: 2-nonanone; 6-methyl-5-hepten-2-one; linalool; δ-decalactone, and δ-undecalactone. The lactones were also tested on the yellow fever mosquito Aedes aegypti (Stegomyia aegypti) (Diptera: Culicidae), against which they showed similar degrees of repellency. We conclude that the lactones are highly promising repellents, particularly because these compounds are pleasant-smelling, natural products that are also present in human food sources.

Surgery of the external nasal valve: the correlation between subjective and objective measurements.

OBJECTIVES/HYPOTHESIS: Minimum cross-sectional area of the nasal passage on CT (CT-MCA) is an objective computerised determination of the minimum cross-sectional area of the nasal passage on CT. CT-MCA was evaluated before and after surgery on the external nasal valve using the 'lateral crus pull-up' procedure (LCPU). The outcomes of CT-MCA were compared with other currently available objective tests for nasal valve patency. STUDY DESIGN: Prospective cohort study. METHODS: This study included 34 patients undergoing surgery on the external nasal valve with the use of the LCPU technique. CT-MCA was performed before and after surgery and compared with the subjective perception of nasal passage using the Nasal Obstruction Symptom Evaluation (NOSE) scale and with objective tests such as acoustic rhinometry (A-MCA), rhinomanometry (NAR) and peak nasal inspiratory flow (PNIF). RESULTS: This study showed a significant correlation between CT-MCA and the NOSE scale, PNIF and NAR. Paired-samples t-tests showed significant improvement after surgery on CT-MCA, PNIF and the NOSE scale. Multiple linear regression analysis showed that PNIF, CT-MCA and NAR were significantly associated with the NOSE scale. CONCLUSION: CT-MCA and PNIF were both significantly correlated and associated with the patient's subjective perception of nasal passage. The surgical procedure, the 'lateral crus pull-up', showed a significant improvement in the postoperative result both subjectively and objectively.

Lack of efficacy of long-term, low-dose azithromycin in chronic rhinosinusitis: a randomized controlled trial.

BACKGROUND: In persistent chronic rhinosinusitis (CRS), conventional treatment is often insufficient. Long-term, low-dose administration of macrolides has been suggested as a treatment option. The MACS (Macrolides in chronic rhinosinusitis) study is a randomized placebo-controlled trial evaluating the efficacy of azithromycin (AZM) in CRS. METHODS: We describe a group of patients with recalcitrant CRS with and without nasal polyps unresponsive to optimal medical and (in 92% also) surgical treatment. Patients were treated with AZM or placebo. AZM was given for 3 days at 500 mg during the first week, followed by 500 mg per week for the next 11 weeks. Patients were monitored until 3 months post-therapy. The assessments included Sino-Nasal Outcome Test-22 (SNOT-22), a Patient Response Rating Scale, Visual Analogue Scale (VAS), Short Form-36 (SF-36), rigid nasal endoscopy, peak nasal inspiratory flow (PNIF), Sniffin' Sticks smell tests and endoscopically guided middle meatus cultures. RESULTS: Sixty patients with a median age of 49 years were included. Fifty per cent had asthma and 58% had undergone revision sinus surgery. In the SNOT-22, Patient Response Rating Scale, VAS scores and SF-36, no significant difference between the AZM and the placebo groups was demonstrated. Nasal endoscopic findings, PNIF results, smell tests and microbiology showed no relevant significant differences between the groups either. CONCLUSION: At the investigated dose of AZM over 3 months, no significant benefit was found over placebo. Possible reasons could be disease severity in the investigated group, under-dosage of AZM and under-powering of the study. Therefore, more research is urgently required.

Osteitic bone in recalcitrant chronic rhinosinusitis.

INTRODUCTION: There is increasing interest in the underlying bone of the paranasal sinuses as an important player in recalcitrant Chronic Rhinosinusitis. Close inspection of CT scans often reveals areas of increased bone density and irregular thickening of the sinus walls. This osteitic bone could at least partly explain, why inflammation of the mucosa persists. METHODS: We searched PubMed for all relevant studies, using the following text words: chronic rhinosinusitis, sinusitis, bone, osteitis, osteomyelitis, histology, and treatment. Cited references of retrieved articles were also examined. RESULTS: Background, available data, potential diagnostic options, treatment implications, and suggestions for future research are discussed. CONCLUSION: Osteitis is associated with CRS, however its role in the pathogenic process is not well defined. More research is needed.

The aetiology of otosclerosis: a review of the literature.

During the last century, hundreds of studies have been performed to identify factors that are involved in the aetiology of otosclerosis. These studies include a variety of aetiological factors and, although many theories have been postulated, the process of the development of the disease remains unclear. A historical overview and analysis of the literature dealing with the aetiology of otosclerosis is presented. The role of collagen disorders, genetic linkage studies, associations with the HLA system and measles virus infection as causal factors is discussed. From an epidemiological point of view, the disease has an autosomal dominant mode of inheritance. Therefore, since the introduction of new genetic research techniques over the last decades, more studies have been performed to find evidence of a genetic factor that initiates the development of otosclerosis. In this review, we tried to categorize the most prominent studies in sections according to their subjects within the diversity of aetiological factors that have been studied.

Pneumocystis carinii infection of the middle ear and external auditory canal. Report of a case and review of the literature.

We present a 50-year-old male with Pneumocystis carinii infection involving the middle ear and the external auditory canal as the first manifestation of a previously unknown HIV infection. In case of therapy-resistant otitis with a polypoid mass in the external auditory canal histological evaluation should be considered to rule out malignancy or pathogens, like Pneumocystis carinii, that cannot be cultured. Oral or intravenous antiprotozoal agents are the treatment in line with current practice. Exploration of the os petrosum is never required.